The desire to bear children can be extremely strong. When that desire reaches a barrier, the resulting challenge can be very stressful to a couple, among the strongest sources of stress that can occur.
But how prevalent is this concern. Certainly, the conventional wisdom is that the rate of infertility in the United States is increasing. The aging of the population as the baby boom generation matures and share increasing stories about their infertility stories have undoubtedly contributed to the popular notion that infertility rates were increasing.
Societal and behavioral hanges in the last 50 years might have affected the rate of fertility. Specifically, the trend toward delayed childbearing, which I have written about more extensively is a factor. The mean age of first births occurring in women aged 30 years or over has increased more than 6 fold between 1970 and 2002 from 3.9% to 25.1%. This is related to increases in the female labor force participation and has been seen. There has also been a tremendous gain in educational achievement. Between 1970 and 2020 completion of 4 years or more of college rose form 8% to 25% of women aged > 25 years.
It is in this context that we introduce one measure of infertility prevalence
Surveys done by the CDC provide most of the American Data regarding infertility. he surveys, first done in 1965, were last done in 2002 and show a relative decrease in infertility from 11.5% in 1965 to 7.4% in 2002. What lies behind this number, though, might be a little more complex than first glance. As surveys, they represent self reported data, which may be affected by the perception of the responding people.
Another way to look at the issue is by seeing what percentage of women seek fertility care. In the United States, as in many places around the world, over 50% of surveyed women have sought fertility care of some type. This could be reflected in the prevalence data in that more women seek care faster and reach resolution of their concerns faster. This data is why the World Health Organization has recognized infertility as a public health issue in 2001.
This is also reflected in the increase in the use of advanced reproductive technologies. The Centers for disease control collects annual data from fertility clinics in the United States. Here is the trend in the use of IVF from 2000-2009.
Is infertility a Disease?
This is a really tough question. So much of the infertility issue comes down to factors of choice. Liberal use of contraception and the high number of cohabitating couples who seek to delay childbearing seem to shroud the fact of infertility into the choices couples make. It isn’t a chronic disease, like diabetes or hypertension, which also may have a lifestyle component. But infertility can be a byproduct of other chronic diseases.
Asking if Infertility is a disease is a little like asking if obesity is a disease. There are parallels. Both come as a result of lifestyles, increase as people get older, and may require significant technology to overcome. But the institute of medicine did not seem to agree, as they did not include infertility in the list of essential health care benefits in the Patient Protection and Affordable Care Act (Obamacare). Most insurers do not cover obesity treatment.
Likewise, insurers do not cover infertility treatments liberally. Only 15 states cover infertility treatment. Resolve, the infertility support group has lobbied for infertility to be included as an essential health care benefit
Unlike Obesity or other chronic diseases, Infertility poses no threat to the patient’s physical health if left untreated. It does not directly affect the daily life of the couple. But Rather than a disease, perhaps it can be classified a disability. The Supreme Court of the United States may have started this process with a 1998 decision Bragdon v. Abbott, where the Court used the deterrent effects of HIV upon a woman’s ability to reproduce rather than the debilitating effect of the person’s ability to fight off and survive the disease. This led to a series of litigation designed to test and codify infertility as a disability and a right. in 2008, amendments to the Americans for disability went into effect, which included reproductive function both as a physical or mental impairment and a major life activity.
This has led most recently into a well publicized test by an Indiana couple seeking damages against an employer under the Americans for Diability Act. The EEOC upheld Herx’s complaint in January.
This appears to be a lot of work for a condition that affects less than 8% of reproductive age couples. While the law seems to describe pregnancy as a right, most, if not all rights are not concrete. Consider health, freedom,safety, even privacy. All are rights of a sort, yet none have tangible structure. Perhaps when children were more seen as a gift, it was more seen as a part of the cycle of life, not as a disease or disability. More research, indeed needs to be done, but maybe some very simple changes in the behavior of the population may have a major impact on the prevalence.